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Commemorating the #urojc one year mark, Brian Stork reflected on the year that was, with a fun visual diagram on the most common words used during this period.
A fitting paper for moving into Season 2 of the #urojc, with the November International Journal Club discussion on Twitter was based on the paper “Detrusor Underactivity and the Underactive Bladder: A New Clinical Entity? A Review of Current Terminology, Definitions, Epidemiology, Aetiology, and Diagnosis” by Osman et al from European Urology, 26 October 2013.
Osman et al, attempted to provide clarity around the nonobstructive impairment of voiding function, referred to as detrusor underactivity and the underactive bladder, as a clinical entity, and provide consensus on the standardising of current concepts. In their attempt to achieve this aim, a wide ranging literature review was conducted on varying terms commonly pertaining to detrusor underactivity.
So, does definition matter when discussing bashful bladders?
Early discussion centred on how frustrating detrusor underactivity was as an entity in part due to lengthy and complex mathematical equations,
difficult in defining, with Amrith Rao, adding another term into the mix,
and often concomitant disease processes.
Surgical intervention for a bashful bladder is not a new concept, with Amrith Rao noting a partial cystectomy for hypotonic bladder was offered in the 1970’s.
This lead to a clinical discussion with participants asked who would perform a TURP on a man with an underactive bladder as suggested by urodynamics? Nadir Osman brought to our attention a study published in The Journal of Urology by Djavan et al in 1997, which concluded patient age was the key factor in treatment failure. However, with no solid evidence, participants agreed it often came down to patient choice.
Although a smaller group of participants for this month’s discussion, conclusions included:
The main messages I took from this discussion were:
This month had a strong showing from Sheffield urologists and alumni including Nadir Osman, Kate Linton, Jake Patterson, Jim Catto, Henry Woo and Chris Chapple who was listening in from his newly created Twitter account. The winner of the best tweet prize for the November #urojc is Jake Patterson. BMC Urology have kindly donated a complimentary manuscript submission to this open access journal (of course pending peer review process).
Whilst these non-oncology topics see smaller participation, these topics will continue to be supported to provide variety and to maintain interest to the general #urojc audience.
Helen Freeborn is an Australian Urology Trainee, currently completing a General Surgical year at Cairns Base Hospital, QLD. She is interested in surgical leadership and the power of social media in connecting health professionals. Twitter @DrHelenF
In the accompanying paper, Yan et al. [1] present the outcomes of their study on percutaneous nephrolithotomy (PCNL) guided only by ultrasonography (US).
This is the largest series (705 patients) to date on PCNL purely under US control and reports stone-free and complication rates that are consistent with those commonly reported for PCNL guided by X-ray or by a combination of X-ray and US.
Since its introduction more than three decades ago, PCNL has traditionally been performed under fluoroscopic control by the majority of urologists, even though US guidance has now gained wide acceptance as a means of achieving renal access. Now, the most important international guidelines suggest that US be used in addition to fluoroscopy [2]. US guidance has the following advantages: it minimizes radiation exposure, allows the detection of viscera that can sometimes lie in the trajectory of the puncturing needle and avoids contrast-related complications. Furthermore, US provides imaging of the collecting system in three-dimensional orientations and helps to distinguish between anterior and posterior calyces with great accuracy. Nevertheless, the innovative concept proposed by Yan et al. [1], with their impressive series, concerns the whole procedure (puncture, creation of renal access and final look to rule out eventual residual fragments), and not only the safe accomplishment of the puncture solely under US guidance.
Caution should be taken in interpreting their results. This is a purely retrospective study which guarantees only a low level of evidence (3B). In addition, even though major complications arising during the creation of access were not reported in the paper, doubts remain about the safety of using only US guidance in monitoring the dilatation process by either balloon or coaxial dilators. The following questions still need to be addressed. How can the progression of dilators be monitored to avoid excessive inadvertent medial advances with the accompanying high risk of collecting system perforation? How can false passage of a working guidewire be detected early by US? What about obese patients in whom the effectiveness of US is generally impaired?
To balance the risks and benefits of guidance solely by US, a middle ground could be represented by US guidance aided by ureteroscopic monitoring of the dilatation process using the so-called ‘Endovision technique’ [3], as is possible during endoscopic combined intrarenal surgery (ECIRS) (Fig. 1). In view of the risks, it should be stressed that, even though PCNL guided solely by US is an attractive option, biplanar C-arm fluoroscopy should always be present in the operating room.
It is well known that radiation hazard is directly proportional to cumulative radiation exposure time, so US guidance provides an obvious advantage in terms of absence of radiation for patient and operating room staff, but is the extent of this advantage really known? It is important to underline that the amount of radiation exposure during PCNL is not particularly great, measuring on average 0.56 mSv for the patient and 0.28 mSv for the urologist [4]. By contrast, unenhanced CT involves a significant radiation exposure of 8.6 mSv [5], which is of course particularly relevant for patients with stones, who are often quite young and likely to experience recurrence. According to the ‘as low as reasonably achievable’ (or ALARA) principle, replacing CT scans with US in the follow-up would have a much greater impact on reducing radiation exposure in adult patients (in the present series patients undergo two CT scans after surgery, at 48 h and 4 weeks, and one preoperative CT scan!) than would renouncing the safety guaranteed by X-ray monitoring during endourology.
Finally, it is of paramount importance to stress that, in the current climate in which malpractice litigation related to endourology continues to rise [6], it is still advisable that PCNL guided solely by US should be performed only in trials for which approval of the local institutional review board has been obtained.
To conclude, Yan et al. [1] propose an alternative approach to PCNL that involves solely US guidance, but some doubts remain. Only further well designed, prospective, comparative and possibly randomized studies will allow us to draw definitive conclusions.
Guido Giusti
Head of Stone Center & European Training, Center in Endourology, Humanitas Clinical and Research Center, Milan, Italy
References
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Virtual prostate biopsy and biopsy simulation: lessons to be learned
Prostate biopsies, transrectal or transperineal, still constitute the pillars of prostate cancer detection today [1]. With the lack of reliable imaging tools (new MRI techniques are promising but still investigational [2]); random biopsies offer the sole adequate cancer detection option [3]. However, random biopsies are far from efficient in detecting all tumours and even less efficient in detecting all significant cancer ‘spots’. To improve sensitivities and specificities, increasing the biopsy core numbers, targeting more lateral aspects and encouraging repeat biopsies have been recommended [4]. Recently, HistoScanning™ [5] and template biopsies [6] have been introduced to further improve biopsy quality and efficiency. The latest innovations include the fusion of MRI pictures with the TRUS image to offer optimal targeting of suspicious areas [7]. And yet, these efforts are far from solving the main problem. How can we perform a biopsy and be confident to detect most of the cancers, i.e. significant malignant areas.
The present study [1] does, what should have been done a long time ago, namely to create a reliable and reproducible biopsy simulation model to allow the investigation of various biopsy schemes, core lengths and numbers. Based on a series of 109 radical prostatectomy specimens, a three-dimensional (3D) prostate and prostate cancer model was created using novel 3D slicer software and various prostate biopsy schemes were simulated. Using this method, the detection rate for tumours with a tumour volume (TV) of ≥0.5 mL plateaued at 77% (69 of 90) using a 12 core (3 × 4) scheme, standard 17-mm biopsy cutting length without anteriorly directed biopsy (ADBx) cores. Twenty of 21 (95%) tumours with a TV of ≥0.5 mL not detected by this scheme originated in the anterior peripheral zone or transition zone [1].
Confirming our earlier data with the Vienna nomograms [8], increasing the biopsy cutting length and depth/number of ADBx cores (14–18 cores) improved the detection rate for tumours with a TV of ≥0.5 mL in the 12-core scheme [1]. The best biopsy scheme used a 22-mm cutting length and a 12-core scheme with additional volume-adjusted ADBx cores. Using this combination, 100% of ≥0.5 mL tumours in prostates <50 mL in volume and 94.7% of ≥0.5 mL tumours in prostates >50 mL in volume were detected.
Certainly, these numbers will not be reproducible in real-time TRUS or transperineal biopsies (detections rates of 95–100% as seen in this simulation model, cannot be achieved without adequate imaging tools, which are not available yet), but they aid significantly in rethinking our biopsy strategy. So, if we summarise the present findings and combine them with published data, the future will demand a TRUS-fusion biopsy technique, involving 14–18 cores (or more if volume increases), involving the anterior zones of the prostate and using a 22-mm cutting length of the biopsy core vs a 15–17 mm core as is used currently. Obviously real-time prospective trials are needed to confirm these findings but nothing indicates that the outcome would be otherwise.
Bob Djavan
Department of Urology, New York University School of Medicine, NYU, New York, NY, USA
References
Over the last decade, urological researchers have been increasingly interested with, and driven by, the impact factor (IF) of the journal to which they are submitting. This bibliometric tool measures the way in which a journal receives citations of its articles over time. IF is calculated by dividing the number of current citations a journal receives for articles published in the two previous years, by the number of articles published in those same years.
Although IF represents a proxy for the popularity of a journal within its field, several academic and scientific organizations now use the IF to judge the value of a scientist or of a research team using it for national and international academic evaluations. This questionable policy has generated a vicious circle that has driven authors to prefer journals with higher IFs and, consequently, journal editorial boards (and publishers) to plan (soft or strong) strategies to increase this index. As a result a higher IF attracts the best articles in the field and increases the number of subscriptions to a journal. There are a number of potential biases influencing the IF values including self-citation, the number of articles published per year, and the type of articles accepted. We will explain how all of these nuances can play a significant role in calculating the IF.
Some journals subtly suggest that authors and reviewers cite articles published in their own journal within the references of newly submitted papers. This slightly dubious practice can bias the true value of the IF. Reassuringly when looking at the urological journals, the self-citation factor generally seems to play a limited role, as most journals have a percentage <10%. The policy of the BJUI Editorial Board does not support a self-citation practice. The decision to start each BJUI issue with some editorial comments (the Editor’s Choice section) is only to offer to readers the opportunity to have expert comment on the most important papers published within each edition. Indeed, the invited authors are only requested to cite the featured article and no others from the BJUI.
The number of papers published per journal volume and throughout each year is another significant factor influencing the IF value. Table 1 clearly shows the wide variability in the number of papers published from 2010–2011 in the different urologic journals. The new BJUI policy is to significantly reduce the number of published papers/year. Reflecting this decision, the BJUI Editorial Board has agreed to significantly improve the review process with the aim of selecting only the most relevant and original of the submitted manuscripts. A new rapid triage review process should allow us to select only the best 30–40% of submitted manuscripts to send to 3–4 experts for a more focused and precise review process. This mechanism has produced a significantly increased rejection rate in favour, we hope, of a better selection of topics and papers for our readership [2].
| Abbreviated Journal Title | Cites in 2012 | Items published in 2010–2011 | Impact Factor |
|---|---|---|---|
| EUR UROL | 4.662 | 445 | 10.476 |
| NAT REV UROL | 580 | 121 | 4.793 |
| PROSTATE | 1.395 | 963 | 3.843 |
| J UROLOGY | 4.864 | 1316 | 3.696 |
| J SEX MED | 2.638 | 751 | 3.513 |
| BJU INT | 3.323 | 1091 | 3.046 |
| WORLD J UROL | 673 | 233 | 2.888 |
| UROLOGY | 2.843 | 1173 | 2.424 |
| CURR OPIN UROL | 360 | 164 | 2.195 |
Bibliometric analyses have shown that review articles are cited more frequently than full original research papers. Therefore publishing good quality review articles written by expert opinion leaders in the field represents an excellent strategy to increase a journal’s IF. Although, we recognize the impact of review articles on IF, the current policy of the BJUI remains unchanged with only relatively few review articles included in each issue. As a result we will continue to give maximal attention to the clinical and basic research papers.
Finally the IF is in many ways only an index of the popularity of a journal because it equally weights citations from highly reputed journals alongside citations from more obscure journals [1]. However a journal’s true credit is also based on the prestige of the citing journals and the Eigenfactor scores is currently used to reflect this measure. Table 2 shows that the BJUI is third of all urological journals according to this less popular bibliometric tool. Another contemporary measure of impact, particularly influenced through the internet is the “Klout Score”. This system, which uses social media analytics to rank users according to online social influence via the Klout Score, giving a numerical value between 1 and 100. The BJUI currently has a score of 56, higher than its contemporaries. Therefore we can conclude that the BJUI today is a journal with a good reputation throughout the urologic field.
| Rank | Abbreviated Journal Title | Eigenfactor® Score | Impact Factor | IF rank |
|---|---|---|---|---|
| 1 | J UROLOGY | 0.08109 | 3.696 | 4 |
| 2 | EUR UROL | 0.05503 | 10.476 | 1 |
| 3 | BJU INT | 0.04248 | 3.046 | 7 |
| 4 | UROLOGY | 0.03896 | 2.424 | 11 |
| 5 | J SEX MED | 0.01738 | 3.513 | 6 |
| 6 | PROSTATE | 0.01624 | 3.843 | 3 |
| 7 | J ENDOUROL | 0.01571 | 2.074 | 15 |
| 8 | NEUROUROL URODYNAM | 0.00897 | 2.674 | 10 |
| 9 | WORLD J UROL | 0.00750 | 2.888 | 8 |
| 10 | INT J UROL | 0.00582 | 1.734 | 16 |
The editorial board of a traditional urological journal like the BJUI must take into consideration both the IF and other scoring systems as indicators of its popularity and prestige. The strategies we employ to give better bibliometric parameters should predominantly reflect an increase in the quality of the papers published as we must remember that the journal is primarily produced for the readership and not just for those who wish to publish in it [3].
Vincenzo Ficarra1, Associate Editor,
Ben Challacombe2, Associate Editor,
Prokar Dasgupta2, Editor in Chief
1Department of Experimental and Clinical Medical Sciences, Urology Unit, University of Udine, Italy. 2King’s Health Partners, London UK
References
Original publication of this editorial can be found at: BJU Int 2013; 112: 873–874, doi: 10.1111/bju.12472
November marked the first anniversary of the International Urology Journal Club on Twitter. As far as we are aware, our #urojc was the first journal club on Twitter using the asynchronous format. Prior to our commencement and unknown to us, a very successful real time journal club had been established with great success. Our major challenge was to enable engagement from our global community and clearly the way forward was to use the asynchronous chat format. This has since proved to be the innovation that has enabled true global participation. Other specialties have since followed our model.
When we started, we were fortunate to be in a specialty group where there were already significant numbers on Twitter and we were able to rally up the troops for the first #urojc discussion in November 2012. In the first month of our existence, we had around 50 followers and since then there has been a steady growth in those following the #urojc account and as we reached our one year anniversary, we had hit the magic 1000 follower mark.
Before all is relegated to faint memory, it is important to acknowledge the supporters and Best Tweet (Hall of Fame) winners over the past 12 months.
A couple of the novel prizes, were not sur‘prize’ingly from Urology Match.
Thanks to all of you who have supported this project as participants and followers of the #urojc discussions. A shout out to BJUI for allowing us to have the audience of the BJUI Blogs to communicate and publicize our activities. Thank you to the supporters of the Best Tweet Prizes and the journals who have kindly allowed open access of articles discussed. A special thanks to authors who have been kind enough to make themselves available for the discussion – having author insights adds a special touch that is simply not possible with any other journal club format.
We have been off to a strong start for our second year and look forward to the continued success of this novel form of CME by social media.
Henry Woo is an Associate Professor of Surgery at the Sydney Adventist Hospital Clinical School of the University of Sydney in Australia. He has been appointed as the inaugural BJUI CME Editor. He is currently the coordinator of the International Urology Journal Club on Twitter. Follow him on Twitter @DrHWoo
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Greetings from Colombo, Sri Lanka. Home of the Inaugural Meeting of BAUS / SLAUS. The gathering, held in cool Colombo was off to a great start at Asiri Surgical Hospital. It was inundated with delegates from all over Sri Lanka and the UK, who had come to learn and exchange opinions. The conference started with a focus on LUTS. Mr. Mark Speakman (Taunton, UK) emphasizing importance and correct terminology used in treatment of this condition. This was followed by Mr. Pallavoor Anandaram (Wrexham, UK) and Mr. Ian Pearce (Manchester, UK) talking on medical management the pros and cons, with great debate and participation from delegates. This was followed by Mr. Peter Acher (Southend, UK) covering surgical management of LUTS.
Lunch was held on the rooftop terrace, with gourmet Sri Lankan cuisine. The afternon was filled with laparoscopic talks led by Mr. Christian Brown (London, UK) with Mr. Sanjeev Madaan (Dartford, UK) reflecting on use of cryotherapy importance, technique and complications.
In addition there was also a live surgical link up with Mr. Ranjan Thilagarajah (Chelmsford, UK) conducting live robotic surgery at Kings College. This was streamed to Australia, USA, Sri Lanka and the UK.
In true Sri Lankan fashion, the day concluded with a welcome dinner, and exchange of gifts for the Faculty. All in readiness for a new day!!!
The day kicked off to a bright start discussing complex MDT cases, with a combined panel from the UK and Sri Lanka. Involved in discussions were Dr. Serozsha AS Goonewardena (Colombo, Sri Lanka), Prof. Raj Persad, Mr. Sanjeev Madaan, Miss Sanchia Goonewardene (London, UK). There were a variety of cases covered including prostate, bladder and renal cancer and a variety of management strategies discussed.
As before, local gourmet cooking was served for lunch, with the afternoon moving onto a series of lectures. Firstly was Mr. Ian Pearce (Manchester, UK) on how to get a paper published. Secondly, Miss Sanchia Goonewardene on UK training, followed by Mr. Sohan Perera (Colombo, Sri Lanka) on Sri Lanka training. Mr. David Tolley (Edinburgh, UK) then covered aspects of educational involvement from the college, and the afternoon ended with Mr. David Jones (Gloucester, UK) explaining the process of internal review. A welcome address was conducted by Mr. Anura Wijewardane (Colombo, Sri Lanka), then Chief Guest Mr. Mark Speakman spoke, before an address by the Guest of Honour, Dr. Athula Kahandaliyanage (Colombo, Sri Lanka).
Both Mr. Mark Speakman and Mr. David Tolley were awarded Honurary Fellowships by SLAUS, before a vote of thanks was conducted by Dr. Ajith Malalasekera (Secretary, SLAUS).
The evening concluded with a cultural show and reception, just what all needed.
The day kicked off with Mr. Vincent Gnanapragasam (Oxford, UK), lecturing on risk stratification on prostate cancer. Mr. Gurpreet Singh then spoke on surgical management of LUTS, including objective assessment of obstruction. An audience vote was taken for surgical treatment, with the vote almost unanimously being in favour of bipolar. Then Mr. Peter Acher spoke on HoLEP, giving the pros and cons of the system. Mr. Christian Brown spoke on greenlight laser, therapy and protocol involved. This revealed a ground breaking moment as he presented new data on green light vs. TURP (unpublished).
Overactive bladder symptoms and treatment were then discussed by Ms. Tharani Nitkunan (Surrey, UK), including at times a mixed response to treatment. Mr. Roger Walker (Epsom, UK) then spoke on stress inconvenience and use of mid urethral tape. Complications of tapes were then covered by Mr. Simon Fulford. Mr. Pravin Menezes (Sunderland, UK) then discussed non communicable disease and types of stone.
Mr. Mark Stott (Exeter, UK) then spoke on urosepsis and mortality, highlighting the importance of preventing urosepsis and early antibiotic therapy. Dr. Anuruddha M Abeygunasekara (Colombo, Sri Lanka), then spoke on GU TB. This was especially interesting to the UK delegates, like that we do not see.
Mr. Mark Speakman then gave the SLAUS lecture on prostate cancer incidence and trials involved.
After lunch, uro-oncology was covered by both Mr. Thiru Gunendran (Manchester, UK) and Prof. Raj Persad. Also during the afternoon was the trainees forum ranging from stone disease to uro-oncology to new techniques for urethral pull-through for management of membrano prostatic disease.
After tea came management of spinal cord injury by Mr. Simon Fulford and Mr. Julian Shah, before facilitation of UK fellowships by Mr. Ranjan Thilagarajah and management of vesico-vaginal fistulae by Mr. Julian Shah.
The evening ended with a closing ceremony and banquet.
Sanchia Goonewardene and Raj Persad*
Homerton University Hospital, London and *Bristol Urological Institute, Southmead
[caption id=”attachment_10517″ align=”alignleft” width=”800′ label=’
Faculty member, Miss Sanchia Goonewardene and President Elect of BAUS, Mr. Mark Speakman at the Faculty Dinner, Pegasus Reef Hotel, Sri Lanka.
Functional outcomes represent relevant criteria to evaluate the success of radical prostatectomy (RP) in the treatment of localised and locally advanced prostate cancer. Indeed, while the primary goal of RP remains the complete extirpation of the primary tumour, patients’ satisfaction can be negatively affected by urinary incontinence and/or erectile dysfunction after RP.
In this issue of BJUI, Geraerts et al. [1] evaluated urinary continence recovery and voiding symptoms in a well-conducted, single-centre, prospective non-randomised study comparing two contemporary series of patients who underwent either open retropubic RP (RRP) or robot-assisted RP (RARP) for clinically localised or locally advanced prostate cancer. Patients were assigned to each group according to their or their surgeon’s preference. High-risk prostate cancers were preferably treated with an open access to offer a more accurate extended lymphadenectomy. The study showed that the urinary continence recovery rate was significantly shorter in the RARP group than in the RRP group (16 vs 46 days; P = 0.008). Interestingly, the RA approach remained an independent predictor of time to urinary continence recovery on multivariable Cox regression analysis (P = 0.03; hazard ratio [HR] 1.52, 95% CI 1.03–2.26). Therefore, this study confirmed previously published results. In 2003, Tewari et al. [2] reported a shorter time to recovery of urinary continence in patients who underwent RARP (44 days) than those who received RRP (160 days). In 2008, Kim et al. [3] reported a median time to continence in RARP patients of 1.6 months, significantly lower than the 4.3 months in the RRP patients. Interestingly, Geraerts et al. [1] identified other independent predictors of time to continence, such as patient’s age >65 years (P = 0.02; HR 0.67, 95% CI 0.45–0.96) and the preoperative continence status (P = 0.004; HR 1.69, 95% CI 1.18–2.43). In all, 28% of patients who received RRP and 34% of those who underwent RARP were preoperatively defined as incontinent using a symptom-specific questionnaire [1]. These patients classifiable as ‘Cx’ according to the Survival, Continence and Potency (SCP) classification [4] represent a confounding population in the Geraerts et al. study who should be evaluated separately.
An interesting question is whether the reported difference in time to continence in favour of RARP is also significant from the clinical perspective. Urinary continence in patients who underwent RARP recovered 1 month early than those treated with traditional RRP. The King’s Health questionnaire seems to confirm a positive effect of this outcome on the patient’s quality of life (QoL). Indeed, there were better results in the RARP compared with RRP group at 1 and 3 months after RP. Moreover, at 12 months after RP, patients who underwent RRP were more physically limited (P = 0.01) and took more precautions to avoid urine loss (P = 0.01) than those who received a RARP [1]. These data seem to be in conflict with the reported overlapping 12-month urinary continence rates (96% in RRP and 97% in RARP group). Moreover, looking at the 12-month urinary continence rate, the Geraerts et al. study does not confirm the results of a recent cumulative analysis of available comparative studies showing a better 12-month urinary continence rate after RARP compared with RRP (odds ratio 1.53; P = 0.03) [1].
Interestingly, the 12-month urinary continence rate reported after RRP by Geraerts et al. is significantly higher (96%) than the values reported in the comparative studies included in the meta-analysis (88.7%) and in the most important and recent RRP non-comparative series (60–93%) [5]. This aspect appears to confirm the important role of surgeon experience. Indeed, in this Belgium series most of the open procedures were performed by an expert surgeon with experience of >3000 RRPs, and thus able to reach excellent functional outcomes for urinary continence recovery. In favour of robotic surgeons, we could consider that they were able to reach overlapping results after <200 cases.
In conclusion, the study published by Geraerts et al. [1] showed that modern RP in expert hands is able to achieve excellent results for urinary continence recovery regardless of the approach. However, pure and RA laparoscopy has pushed open surgeons to improve technical and postoperative aspects to achieve comparable outcomes. RARP can offer some advantages over traditional RRP, above all for the time to reach urinary continence. This advantage seems to have generated a better QoL profile in patients who underwent RARP at 12 months after RP.
However, the choice between the two techniques must be taken according to all the most relevant parameters including perioperative, functional (continence and potency) and oncological outcomes. Therefore, we strongly support the publication of clinical series or comparative studies reporting results according to the ‘trifecta’, ‘pentafecta’ or SCP systems [6].
Vincenzo Ficarra†°, Alessandro Iannetti* and Alexandre Mottrie†
†OLV Vattikuti Robotic Surgery Institute, Aalst, Belgium, °Department of Experimental and Clinical Medical Sciences – Urology Unit – School of Medicine, University of Udine, and *Department of Surgical, Oncologic and Gastrointestinal Sciences, Padua, Italy
References